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FEDERAL EMERGENCY MANAGEMENT AGENCY DATE
PRELIMINARY DAMAGE ASSESSMENT SUMMARY
PART 1 - APPLICANT INFORMATION
COUNTY NAME OF APPLICANT NAME OF LOCAL CONTACT PHONE NO.
POPULATION TOTAL BUDGET MAINTENANCE BUDGET Date FY Begins
Approved Balance Approved Balance
PART II - COST ESTIMATE - SUMMARY (COMPLETE SITE ESTIMATE BEFORE SUMMARIZING BELOW)
CATE- NO. OF Potential Local Funds for Recovery
TYPES OF DAMAGE COST ESTIMATE
GORY SITES FUND/ACCOUNT Available Balance
A Debris Removal
B Emergency Protective Measures
C Roads & Bridges
D Water Control Facilities
E Public Buildings
F Public Utilities
G Recreational or Other
TOTAL TOTAL
0 0
PART III - DISASTER IMPACTS (USE SEPARATE SHEETS IF NECESSARY)
A. GENERAL IMPACT
1. Identify and describe damages which constitute a health and/or safety hazard to the general public.
2. Population adversely affected directly or indirectly by the loss of public facilities or damages.
3. What economic activities are adversely affected by the loss of public facilities or damage?
B. RESPONSE CAPABILITY: Can the applicant respond and recover from the damages quickly and without degradation of
public services? Describe.
C. IMPACT ON PUBLIC SERVICES IF DECLARATION IS NOT MADE: e.g. Deferral of permanent repairs, impact on
ongoing services and capital improvements, etc. Describe.
NAME OF INSPECTOR AGENCY PHONE NO.
FEMA Form 90-80, JAN 84
PDA SUMMARY OF DAMAGES FOR POTENTIAL SUBGRANTEE
Public Entity/Potential Subgrantee Information
Public Entity/Potential Subgrantee Total Operating Budget County Team Leader/Date of PDA
Population Maintenance Budget
Contact and Telephone Number Additional Contacts and Telephone Numbers
Site Estimated Summary
Category Critical Facilities and Inspected Projected Total
Other Damages # of Sites Cost # of Sites Cost # of Sites Cost
Emergency Work
A. Debris
B. Emer. Pro. Meas.
Emergency Work sub-total 0 0 0 0 0 0
Permanent Work
Roads &
C. Bridges
Sub-total 0 0 0 0 0 0
D. Water Control
& Facilities
Sub-total 0 0 0 0 0 0
E. Building &
Equipment
Sub-total 0 0 0 0 0 0
F. Utilities
Sub-total 0 0 0 0 0 0
G. Parks &
Other
Sub-total 0 0 0 0 0 0
Permanent Work Sub-total 0 0 0 0 0 0
Emergency and Permanent Work Total 0 0 0 0 0 0